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General NPI Number Information
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NPI Number | 1649611914
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Entity Type | Individual
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Provider Name | DR. GLEN BALLY
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Gender | Male
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Dates
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Enumeration Date | 07/15/2013
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Last Update Date | 07/15/2013
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Provider Practice Location Address
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Address Line | 3060 MITCHELLVILLE RD SUITE 213
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City | BOWIE
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State | MD
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Zip | 20716-1389
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Country | US
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Telephone | 301-249-1841
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Fax |
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Provider Business Mailing Address
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Address Line | 3313 GRAYVINE LN
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City | BOWIE
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State | MD
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Zip | 20721-2847
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Country | US
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Telephone | 305-487-2015
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Fax |
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 122300000X
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Taxonomy Name | Dentist
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License Number | 7384
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License Number State | MD
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